Traditional Customs and Perceptions During Postpartum Period

Among Rural Cambodian Women

1. Background of the Study

Cambodia is the poorest countries in Asia with high maternal mortality rate (437 deaths per
100,000 live births meaning that every 1,000 birth there are at least 4 women face death risk
during delivery. There are various reasons concerning the cause of death which among those
reasons, traditional beliefs and practices surrounding pregnancy and delivery which were
performed by unskilled traditional birth attendants and women themselves were though as the
major cause of the death. However, there were a few research conducted regarding the issue and a
few ethnographic studies were conducted in rural areas to examine utilization of public health
services.
Meanwhile, the study about traditional customs of rural women during postpartum period is
very limited despite of the study about bad affects of roasting (ang phleung).
Since the standard of living of many Cambodians especially those who live in rural area
whose main career is farming is low (more than 45% of rural people earn less than half dollar a
day) and medically trained health staff is limited (in both quality and quantity) in which every 4
trained midwives served more than 1,000 populations, many Cambodians preferred to get
assistance from the nearest health providers whom they could trust and whose service fee is cheap.
On the other hand, traditional healers as well as traditional birth attendants (TBAs) is available
every rural village.
Traditionally, in Cambodia, traditional beliefs are a mixture of Indian and Chinese medicine
and spiritual animistic beliefs, although the exact origins of many concepts are uncertain.
Cambodians believe in the spirit of trees and ancestors. In every village we can see a small
cottage of neak ta (ancestor spirit), and under trees there is also a small shrine in the form of a
cottage built from hay and containing some offerings. When people are ill they pray and offer an
offering 1 to those spirits to beg their blessings for the sick person. Due to the strong influence of
Chinese medicine, the human body is believed to be combined of 4 elements -earth, water, fire
and wind. Many diseases are believed to be caused by wind (kjol), while fire is used to cure the
diseases. When a person dies, his/her body becomes earth and water. The belief in hot and cold
states of women’s body is strong. For instance, women are believed to be in a cold state in the
postpartum period, so postpartum women are covered with thick clothes from head to toe in order
to avoid wind which causes ill-health in their later age. In contrast, during pregnancy, women are
believed to be in hot state, so they are advised to avoid eating or doing something believed to be
hot.
Most of the extant information about Cambodian beliefs and practices surrounding
pregnancy focuses either on Cambodian refugees in camps along the Thai-Cambodian border or
refugees resettled in third countries. A few studies based in Cambodia included information about
attitudes and practices related to birth are preliminary or evaluative studies performed by NGOs
(Non-Government Organizations) engaged in MCH (Maternal and Child Health) projects.
Moreover, the study of women in refugee camps and those who resettled in third countries do not
represent the current practices and beliefs of Cambodian women. Particularly, it is almost
impossible to find studies of the beliefs and practices of those who live in rural areas.
Finally, scope for incorporation of traditional beliefs and practices into health care in
Cambodia has been neglected, and it remains a key problem in health sector development.
Consequently, I argue that this study is significant in its attempt to maintain indigenous beliefs of
local people instead of replacing those beliefs by modern practices of health care, and in
encouraging cultural rituals which are important factor to support women during postpartum.

1
Offerings for general spirits of trees or ancestors consist of bananas and incense. No money is
included for these offerings.

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 The prime objective of the study was to identify traditional customs which were performed
by many rural Cambodian women where public health facilities access is limited. The study also
seeks to find the impacts of those traditional customs by gathering perspectives from villagers,
yeay mobs and professional health practitioners. By understanding the perceptions of these
practices and the rationale underpinning such practices, the suggestions for incorporating
traditional beliefs and practices into modern health practices policies would find easy way to
reduce maternal mortality and increase utilization of public health services at health centers.
Sixty mothers who have children under three years old were interviewed, fourteen TBAs and
5 health centers’ midwives were also interviewed. I used Cambodian language for the interviews
and after the study finished I translated their words into English language.
2. Traditional Custom during Postpartum Period
Postpartum period is defined by WHO (2001) as the period of immediately after birth until 42
days of birth. In Cambodia, the postpartum period is thought to be longer or shorter depends on
different families condition, some women considered the postpartum period up to more than
ninety days and some considered for less than thirty days. In this study, the postpartum period
was considered immediately after birth until 46 days (one month and half) which is the common
period of majority of women who were interviewed.
The results of the study showed that there were 12 practices were mentioned and performed
by all mothers during postpartum period. Table 1 summarized practices mentioned in which each
practices were categorized according to the percentage of practicing ranking from number one
(high percentage) to twelve (low percentage). Notably, among the practices mothers of delivered
women were the most influential person while relatives (or neighbors) stand in second line and
trained midwives were in the third line of the influential person.
Table 1: Summary of Activities and Practices Mentioned by Women
Activity n (%) of women Range day of Influential person
practicing activity practice First Second
1. Traditional medicine 60 (100) 1-365 Mother Relative
2. Sexual abstinence 60(100) 7-150 Mother Midwife
3. Lying by fire 57(95) 1-15 Mother Relative
4. Avoid taking bath 55(92) 1-30 Mother Relative
5. Hot rock 51(85) 1-7 Mother Relative
6. Food restriction 45(75) 1-150 Mother Relative
7. Steam (spong) 44(73) 1-15 Mother Relative
8. Hot bath 39(65) 1-90 Mother Relative
9. Cover with thick cloth 35(58) 2-90 Mother Relative
10. Restrict from doing hard work 20(33) 7-90 Mother Relative
11. Rest at home 23(38) 7-60 Mother Relative
12. Ice bag on abdomen 9(15) 1-7 Midwife Mother
Source: based on interviews with village women. (n: number; %: percentage)
(a) Perception of Delivery
Normally, immediately after delivery, a woman is considered to be in a cold state because she
lost a lot of blood during delivery. Thus, she needs to restore her balance by adding heat to her
body; otherwise, she will be vulnerable to many diseases in her later age.
Since her body was considered to be in a cold state, the woman has to avoid doing something
or eating something which could make her body cold, for example, she was advised to avoid
eating soup, fresh vegetable, taking cold bath, etc.
(b) Maintaining Body Heat
To maintain her body heat or to restore the heat, the woman is advised to follow several
practices namely drinking traditional medicines, roasting, avoid take bath, taking hot bath, putting
hot rock on the abdomen, steam and cover with thick clothes from head to toes. Traditional
medicine was known as the common practice as all of the 60 mothers in the study drink
traditional medicines during postpartum period. The use of traditional medicines was thought to

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restore heat in the body and to prevent women from being vulnerable to disease or relapse (toah).
Usually, it made from tree barks, tree shoots, tree roots, animal bone, animal lung, specific of
herb, etc. The way of using traditional medicines varied according to the preference of individual,
some women preferred to drink traditional medicines boiled in water, some drink traditional
medicines steeped in traditional rice wine and some preferred to drink both kinds (boiled and
steeped in rice wine).
Since immediately after birth, women
were considered to be in a cold state, she
was roasted to restore heat, to cook her
sawsaye (body strings or vessels), and to
make blood clot flow out. Many respondents
said that their (uterus) pain reduced after
they lied on moderate heat. Another practice
which is believed to maintain heat is to put
hot rock on the abdomen. The average time
of putting the hot rock on the abdomen is 1
hour to 2 hours. It is also believed to reduce
the pain and some women responded that to
space birth, they believed that their belly is
not big if they put the hot rock on their
abdomen. Immediately after birth until one The woman is lying by fire, photo: Health Messenger Magazine
month (majority of) women do not take bath as they thought that they will be suffered from
relapse. So after one month of birth, they take hot/warm bath, this practice mentioned by every
women, they said that if they take cold bath they will frequently have joint pain. Not taking bath
for one month and taking hot bath are believed to make their body warm. Another practice which
is believed to maintain heat in their body is the practice of steam (spong). They boiled herbal
medicines (specific type of grass, tree barks, tree roots, etc.) in a clay pot. Then, they put the clay
pot on the floor where the woman with topless sit, the woman and the hot clay pot is covered with
blanket, this is done until the clay pot runs out of vapor. This practice normally is done after they
ended the practice of roasting. Usually mothers or other family member helps women to do this.
During the postpartum period almost 75% of mothers who experienced delivery were not
allowed to eat some certain kind of foods (such as pig head, bamboo soots, raw vegetable,…).
They were allowed to eat only some certain kind of foods which believed to make their body
warm such as ginger and pepper. Usually, they eat pork mixed with pepper and salt and they
grilled the meat. They tended to eat salty food which could make them more thirsty which could
result in drinking more traditional medicines.
(c) Put Ice-bag on the Abdomen to Reduce Pain
Another practice, which is not commonly done, is putting ice-bag on the abdomen. This
practices is introduced by trained midwife, it is done instead of putting hot rock on the abdomen.
Notably, only those who delivered at hospital or health center and those who are better off could
afford to buy ice and putting it on their abdomen. This is also believed to reduce (uterus) pain.
(d) Other Restricted Activities
The practice of sexual abstinence which is widely done, it is recommended by trained
midwife and mother. This practice and the practice of putting ice bag on the abdomen have no
effect on body warming but they think that these practice are important for them to maintain their
health. Sexual abstinence were followed by all of women.
Some women during postpartum period were not allowed to do hard work (harvesting,
transplanting, ploughing), so they rest at home until they finish the postpartum period. But since
many of women are poor farmers and they live in their own house after marriage, they could not
manage to avoid from doing hard works or rest at home for long. They do their works as normal.

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3. Perceptions of the Practices
Women, TBAs and health centers trained midwives were asked concerning their perceptions
and thinking regarding the practices summarized in table 1. I put the result of the interviews from
perspective of women and TBAs in the same place while the perspective of trained midwives was
categorized in another place which thought as the perspective from professional health
practitioners.
Table 2 shows the thinking of the practices from women, TBAs and trained midwives. I
divided the column in two different categories which are adaptive and maladaptive. The practice
thought to be adaptive is raised from village women as providing good effect on health and they
want to keep practicing it, for the practices considered as maladaptive is thought as providing
both bad and good effects on health, therefore, they thought those practices should not be
integrated into modern health practices. The perception of adaptive and maladaptive of
professional health practitioners was similar. However, many professional health practitioners
considered many practices are in contradict with modern practices.
Table 2: Perceptions of Traditional Customs
Perceptions from Villagers Perceptions from Professional
Practices and TBAs Health Practitioners
Adaptive Maladaptive Adaptive Maladaptive
1. Traditional medicine X X X
2. Sexual abstinence X X
3. Lying by fire X X X
4. Avoid taking bath X X X
5. Hot rock X X X
6. Food restriction X X X
7. Steam (spong) X X
8. Hot bath X X
9.Cover with thick cloth X X X
10. Restrict from doing hard work X X
11. Rest at home X X
12. Ice bag on abdomen X X
Source: Based on the interviews with village women, TBAs and trained midwives
(a) From Perspective of Village women and TBAs
From perspective of women and TBAs majority of the practices they have done were
considered as adaptive to modern health practice, however, they recommended that some practice
should be modified, for instance, the practice of roasting, some women advised that this practice
should not be done too long and the heat of the fire should not be high. Some of the women also
thought that some practices are harmful to their health but they refused to avoid performing them
as they were witnessing their senior relatives got advantage of them. Refer to table 2 summarized
the results of interviews with village women, TBAs and health center trained midwives.
(b) From Perspective of Professional Health Practitioners
Many practices were in contradicted with modern health care. In case a woman got delivery
assistance from trained midwife, she would not be advised or encouraged to perform any practice
which considered maintaining body’s heat. However, all trained midwives advise the practice of s
steaming, putting moderate weight of hot rock on the abdomen, taking hot bath and restriction
from doing hard work or rest at home. Midwives also advised women to restrict from having
sexual intercourse during postpartum period. When a woman delivered her baby at hospital
(according to Maternal and Child Health Center midwife in Phnom Penh, capital city of
Cambodia) she was given a pack of ice to put on the abdomen. However, at provincial and remote
area, the possibility to get ice is far and the price of ice is also expensive.

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6. Bridging the gaps between the modern and traditional health care for development
Based on the understanding of Cambodia’s actual health context, and by comparing
perceptions of the practices from perspective of village women, TBAs and trained midwives,
several policies implications were noted to improve women health and increase public health
utilization.
Firstly, local beliefs and practices should be respected by professional health practitioners
and the program of integration of harmless local beliefs and practices should be included into
study curriculum of training health providers. The disrespect of those the local beliefs and
practices may make local villagers feel marginalized and isolated from modern health care.
However, those beliefs and practices which are harmful should be educated to all people with
evidence-based explanations. The program of health education should not target only women in
reproductive age but also men and their significant relatives such as mothers, grandmothers as
those people have potential influence on the women’s decision making. However, the blending
of the modern and traditional practices during delivery has been undergoing by trained midwives
and TBAs but not all of them recognize this. For instance the practice of using hot rock or ice bag
put on the abdomen after birth is widely practiced and accepted. Health education through mass
media (TV and radio) should increase time of the education (currently the time of health
education broadcasting lasts from 3 to 5 minutes). Moreover, health education campaign should
be done frequently especially in the areas where are far from health centers.
Since the majority of delivery were taken at
home and more than 50% were handled by TBAs, the
program of training TBAs should be expand nation-wide.
Majority of TBAs report to use their skills learned from
mothers, relatives or someone else. In the study, 2
among 14 TBAs were not trained because they were too
old and they are illiterate. All of the TBAs were trusted
by many women, they were considered as the women
relatives. Moreover, during labor, TBAs reported to give
the woman massage on her back and support her Traditional Birth Attendants (yeay mobs) training, photo: Racha
physically and mentally. After the training, there should
be follow up program and refresher training program on the practical ability of those TBAs. In
Cambodia, there is policy to support TBA training program, in the training program TBAs are
trained about technical skills of delivery, referring case for women with danger signs to health
center or referral hospital. At the end of the course, all TBAs have meeting with the health center
every three months to report about their works. All TBAs in the study sell delivery kits to women
and all of them reported to use the kit for delivery.
The program of postpartum care should be implemented not only at health center but also
in village during monthly outreach activities. Many women in the study reported not have ever
been receiving such a service during health center outreach activities, some women when there is
problem occurred called TBA for help. Moreover, after delivery all TBAs reported that to visit
the women’s house for at least three days to see if there is problems or something abnormal.
Lastly, there needs to do more scientific research concerning the practice of drinking
traditional medicines during postpartum about its effect on women and their newborn health. All
of the women in the study drink traditional medicines during postpartum period up to one year or
longer. Some people find the ingredients of the traditional medicines by themselves or some buy
them from traditional healers. Therefore, the practice of combining traditional medicines by
traditional healers should be taken into consideration especially those who sell traditional
medicines to women to use during after birth as the effects of medicines could affect both
mothers and their babies.

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